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AN 


INAUGURAL  DISSERTATION 


PUERPERAL  FEVER. 


AN 


INAUGURAL  DISSERTATION 


ON 


PUERPERAL  FEVER. 

SUBMITTED  TO  THE  PUBLIC  EXAMINATION  OF  THE 

FACULTY  OF  PHYSIC 

UNDER  THE  AUTHORITY  OF  THE  TRUSTEES  OF  COLUMBIA  COLLEGE, 
IN  THE  STATE  OF  NEW-YORK, 

The  Right  Rev.  BENJAMIN  MOORE,  D.D.  President; 

FOR  THE  DEGREE  OF 


^ 


On  thairst  Day  of 


SwtJu  J 

f  OF  WW&Pf 


BY  EZEKIEL  OSTRAN 

Citizen  of  the  State  of  New-York. 


NEW-YORK: 

Printed  by  T.  6?  J.  SWORDS,  Printers  to  the  Faculty  of  Physic 
of  Columbia  College,  No.  160  Pearl-Street. 


1804. 


m 


?W 


TO 


DAVID  HOSACK,  M.  D. 

Professor  of  Botany  in  Columbia  College,  Member  of 

the  Linnaean  Society  of  London,  and  of  the 

Royal  Medical  and  Physical  Societies 

of  Edinburgh,  &c.  &c. 

THIS  DISSERTATION 

Is  respectfully  inscribed. 


INTRODUCTION. 


I  HERE  is  no  disease  in  the  catalogue  of  human 
calamities  upon  which  physicians  have  entertained 
such  opposite  opinions  as  that  which  is  the  subject 
of  this  Dissertation. 

Some  consider  it  a  disease  of  great  exhaustion 
and  putridity,  and  frequently  contagious;  while 
others  believe  it  to  be  an  inflammatory  fever.  From 
the  influence  of  these  two  opinions,  it  must  ap- 
pear that  its  treatment  varies  with  different  persons. 
Those  who  adopt  the  idea  of  putridity  believe  that 
tonics  and  antiseptics  are  the  only  remedies  calcu- 
lated to  give  the  patient  any  chance  of  recovery; 
while  those  whose  speculations  are  drawn  from  ob- 
servation less  exceptionable,  trust  to  the  efficacy  of 
depleting  remedies,  carried  to  a  greater  or  less  ex- 
tent, as  the  necessity  of  the  case  may  require. 

From  the  slightest  observation  of  the  theories  of 
this  disease,  founded  upon  the  above-mentioned 
opinions,  it  would  appear  that  the  facts  upon  which 
they  are  built  were  taken  by  different  men  at  dif- 
ferent periods. 

All  febrile  diseases,  in  their  commencement,  are 
attended  with  increased  action ;  and  the  prominent 


n  INTRODUCTION. 

features  of  this  complaint  are  not  essentially  dif- 
ferent from  other  fevers:  therefore,  judging  from 
the  symptoms  of  its  accession,  it  certainly  would 
appear  inflammatory.  Again,  if  we  suffer  the  in- 
flammatory symptoms  which  characterize  its  in- 
vasion to  progress  without  using  any  means  to  ob- 
viate their  violence,  the  state  of  exhaustion,  in- 
direct debility,  or  collapse,  must  follow  of  conse- 
quence. Now,  discarding  the  inflammatory  symp- 
toms, which  are  comparatively  of  short  continuance, 
and  judging  from  observation  taken  at  this  period 
of  the  disease,  the  opinion  of  its  being  a  disease  of 
exhaustion  would  appear  just. 

The  term  putridity,  as  applied  to  fevers,  is,  in 
my  opinion,  very  improper,  and  ought  to  be  wholly 
exploded  from  medical  writings;  since  it  is  a 
known  fact,  that  the  putrefactive  process  cannot 
take  place  in  animate  matter. 

It  is  remarked  by  some  authors  who  have  treated 
of  this  disease,  that  it  is,  under  certain  circum- 
stances, contagious;  by  others,  that  it  is  always 
the  product  of  contagion  operating  upon  a  system 
predisposed  to  this  disease  by  the  pregnant  and  par- 
turient states.  The  latter  of  these  opinions,  how- 
ever, I  am  inclined  to  disbelieve,  since  we  see  so 
many  sporadic  cases  of  Puerperal  Fever,  in  both 
city  and  country,  originating  from  the  local  situa- 
tion of  the  place  in  which  the  patient  resides,  or 
from  mal-treatment  either  during  pregnancy  or  par- 
turition, and  where  no  circumstance  has  occurred 
which  could  possibly  favour  the  idea  of  a  conta- 


INTRODUCTION.  vii 

giotis  origin.  But  that  the  former  opinion  is  cor- 
rect, viz.  that  this  disease  is  liable  to  become  con- 
tagious under  certain  circumstances,  is  evident  from 
the  following  occurrence,  related  by  Dr.  Thomas 
Young,  Professor  of  Midwifery  in  the  University 
of  Edinburgh;  who  observes,  that  this  fever  was 
unknown  for  many  years  in  the  lying-in  ward  of 
the  Royal  Infirmary  at  Edinburgh;  but  that,  after 
it  was  first  accidentally  introduced  into  the  hospi- 
tal, almost  every  woman  was  seized  with  it  imme- 
diately after  delivery.  He  likewise  remarks,  that 
it  was  only  eradicated  from  the  hospital  in  conse- 
quence of  the  wards  being  entirely  cleared,  and 
thoroughly  cleansed  and  ventilated.  This,  and 
various  other  circumstances  attached  to  yellow  fe- 
ver and  dysentery,  are  calculated  to  illustrate  the 
following  doctrine  of  contagion,  viz.  that  all  con- 
tagious diseases  are  originally  generated  by  the 
combination  of  certain  causes  operating  upon  the 
human  system ;  and  that  the  different  modifications 
or  variations  of  those  causes  will  produce  a  pecu- 
liar action  in  the  arterial  system,  which  shall  secrete 
a  matter  in  some  form  or  other,  depending  on 
the  properties  of  the  stimulus  applied ;  capable,  by 
inoculation,  or  through  the  medium  of  the  atmos- 
phere, to  communicate  the  same  disease,  and  by 
this  means  continue  its  propagation.  Also,  since 
lues  venerea,  small-pox,  scarlatina,  &c.  are  all  more 
violent  and  mortal  in  certain  constitutions  of  the 
atmosphere,  and  even  that  some  of  them  are  gene- 
rated annually,  and  every  three  or  four  years,  in 


vlii  INTRODUCTION. 

certain  seasons,  by  means  of  those  causes.  May 
we  not,  then,  with  the  utmost  propriety,  conclude 
that  all  contagious  diseases  are  originally  thus  pro^ 
duced,  and  that  they  are  consequently  liable  to  be 
again  generated  anew,  in  any  climate  or  situation 
which  is  calculated  to  produce  those  materials 
which  first  gave  origin  to  this  class  of  diseases? 
Most  clearly  we  may;  and  while  the  human  race 
are  increasing  in  number,  large  cities  augmenting, 
and  filth  and  nuisance  accumulating,  the  virulence 
of  all  diseases  will  be  increased,  their  number  en- 
larged, those  that  are  already  contagious  will  be- 
come more  so,  and  those  that  have  not  been  marked 
with  contagion  will,  in  all  probability,  assume  a 
contagious  character. 


AN 

INAUGURAL  DISSERTATION 

ON 

PUERPERAL  FEVER. 


1  HAT  period  of  time  which  intervenes  between 
the  birth  of  a  child  and  the  restoration  of  health 
is  termed  the  puerperal  state ;  and  the  occurrence 
of  fever  during  this  period  has  given  origin  to  the 
name  of  Puerperal  Fever. 

By  this  disease  I  would  wish  to  be  understood 
as  meaning  that  febrile  affection,  the  predisposing 
cause  of  which  may  be  wholly  imputed  to  the 
pregnant  state;  thus  rendering  the  definition  of  this 
disease,  which  is  the  subject  of  my  dissertation, 
more  correct. 

The  history  of  this  disease,  as  laid  down  by  the 
most  celebrated  authors  who  have  treated  on  the 
subject,  appears  to  be  essentially  the  same,  not- 
withstanding they  have  differed  very  materially  on 
the  causes  which  produce  it,  and  on  its  method  of 
treatment. 


10  On  Puerperal  Fever. 

There  is  no  particular  period  after  delivery  iri 
which  this  fever  uniformly  makes  its  appearance; 
it,  however,  most  frequently  commences  about  the 
third  or  fourth  day,  though  sometimes  not  until 
three  or  four  weeks  after  parturition. 

The  symptoms  which  are  indicative  of  the  ex- 
istence or  commencement  of  this  disease  vary  in 
proportion  to  the  predisposition  of  the  patient,  and 
the  operation  of  the  usual  occasional  causes.  It, 
however,  like  all  other  fevers,  generally  commences 
with  a  sensation  of  cold,  succeeded  by  heat,  thirst, 
and  a  frequent  pulse,  which  will  convey  to  the 
touch  a  corded  sensation,  indicative  of  a  high  de- 
gree of  membranous  inflammation.  This,  how- 
ever, is  by  no  means  universally  the  case;  but,  on 
the  contrary,  it  commences  gradually,  and  evi- 
dences itself  by  disagreeable  sweats,  with  nausea 
and  vomiting,  attended  with  looseness  of  the 
bowels.  Neither  is  the  corded  pulse  a  constant 
attendant,  for  although  it  may  be  frequent,  it 
will  be  very  weak,  and  denote  a  great  exhaus^ 
tion  of  sensorial  power  in  the  whole  system,  as  is 
usual  in  inflammation  of  the  stomach  and  small  in- 
testines. As  the  disease  advances,  the  whole  ab- 
domen* becomes  affected,  the  patient  complains  of 
wandering  pains,  which  soon  become  fixed  in  the 
hypogastrium,  where  a  swelling  and  exquisite  ten- 
derness ensue.  She  likewise  feels  great  pain  in 
the  back,  head,  loins,  hips,  frequently  extending 
down  the  thighs,  with  a  frequent  desire  to  mictu- 
rate, accompanied  with  pain,  and  the  evacuation 


On  Puerperal  Fever.  11 

of  a  very  small  quantity  of  urine,  which  is  gene* 
rally  remarkably  turbid.  The  abdomen  is  always 
more  or  less  swelled,  and  sometimes  enlarged  in 
size  nearly  equal  to  what  it  was  previous  to  deli^ 
very,  so  that  she  can  scarcely  lie  in  any  position 
except  on  her  back,  or  on  one  side,  with  her  body 
incurvated.  When  vomiting  is  excited  there  is 
generally  a  dark-coloured  matter  ejected,  appa- 
rently mixed  with  bile  of  a  yellow  or  green  colour, 
attended  with  a  very  bitter  taste.  Vomiting,  how- 
ever, is  not  always  present  in  this  disease,  particu- 
larly in  the  first  stage;  but  nausea,  loathsomeness 
of  the  stomach,  and  an  offensive  taste  in  the  mouth, 
will  scarcely  ever  be  wanting  when  this  fever  is 
completely  formed.  We  sometimes  meet  with  an 
instantaneous  change  in  the  lochia,  which  is  fre- 
quently diminished  and  foetid,  and  sometimes  to- 
tally suppressed:  at  other  times  it  is  not  diminished 
in  quantity,  but  generally  appears  more  or  less  un- 
natural. 

The  secretion  of  milk  is  either  suppressed  or  dir 
minished:  its  appearance  is  usually  very  much 
changed,  and  its  taste  always  altered.  The  sto- 
mach is  so  very  irritable  as  to  render  the  patient 
incapable  of  retaining  any  thing,  except  it  be  very 
cold  or  acid.  Tenesmus  and  frequent  stools  also 
attend  some  cases;  whilst,  on  the  contrary,  others 
will  prove  very  costive,  so  much  so  as  to  render  it 
extremely  difficult  to  obtain  any  evacuation  from 
the  bowels. 

The  tongue  is  usually  dry,  and  covered  with  a 


12  On  Puerperal  Fever. 

whitish  fur,  which,  as  the  disease  advances,  puts 
on  a  darker  appearance,  and  extends  itself  through- 
out the  whole  mouth,  giving  even  to  the  teeth  and 
lips  a  very  sordid  appearance.  At  this  period  there 
is  commonly  a  wildness  to  be  observed  in  the  coun- 
tenance, with  a  flushed  face,  attended  with  a  cough 
and  difficulty  of  breathing. 

The  symptoms  of  inflammation,  together  with 
those  of  extreme  irritability,   will  progress  for  a 
longer  or  shorter  period  of  time,  in  proportion  to 
the  strength  of  the  constitution  of  the  patient,  if 
not  arrested  by  medical  aid;  after  which  the  state 
of  irremediable  collapse,  or  what  has  been  termed 
the  typhoid  or  putrescent  state,   will  commence 
and  evidence  itself  by  the  following  alarming  and 
dangerous   symptoms.      The   pulse  becomes  very 
weak  and  increased  in  frequency;  a  singultus  su- 
pervenes; the  miliary  eruption  which  often  attends 
this  disease,  and  which,  in  the  first  instance,  was 
imperceptible,  now  assumes  a  very  alarming   as- 
pect, indicating  that  the  system  is  labouring  under 
a  state  of  extreme  debility;  the  patient  becomes, 
by  turns,  sensible  and  delirious;  the  sphinctor  mus- 
cles loose  their  contractile  power;  the  urine  and 
alvine  discharges  are  evacuated  involuntarily;  which 
last  are  attended  with  a  very  offensive  faetor,  and 
some  peculiarity  in  their  appearance  ;  they  are  also 
attended  with  an  increase  of  pain  previous  to  the 
evacuation,  and  momentary  relief  in  consequence 
of  the    discharge ;  they   are  of  a   green    or   dark 
brown  colour:  large  hard  lumps  will  sometimes  be 


On  Puerperal  Fever,.  IS 

evacuated,  which  appear  to  have  been  confined  in 
the  intestines  for  some  time  previous  to  delivery. 
There  is  also  a  circumstance  attending  this  stage  of 
the  disease,  which,  I  believe,  has  teen  observed  by 
no  writers  on  this  subject  except  Dr.  Denman, 
who  says,  there  is  an  erysipelatous  tumour  of  a  dusky 
red  colour  on  the  wrists,  elbows,  knees,  and  ancles, 
about  the  size  of  a  shilling  piece,  and  sometimes 
larger,  which  is  noticed  by  him  as  a  symptom  very 
generally  fatal;  and  he  remarks  also,  that  in  those 
cases  the  disease  has  been  found,  by  dissection,  to 
have  affected  principally  the  uterus  and  its  append- 
ages. 

Puerperal  fever,  in  some  patients,  advances  with 
great  rapidity,  and  terminates  their  existence  in  a 
very  short  period.  In  others,  it  progresses  more 
tardy,  and  preys  upon  the  system  for  a  number  of 
weeks,  before  the  patient  falls  a  sacrifice  to  its  ra- 
vages. There  are  some  who  have  died  in  the  first 
cold  stage,  others  in  twenty-four  hours  after  their 
first  seizure.  It  has,  however,  been  asserted  by 
some  authors,  that  the  eleventh  day  proved  fatal 
to  more  women  labouring  under  this  disease  than 
any  previous  or  succeeding  period.  This  doctrine 
of  critical  days,  so  much  advocated  by  many,  is,  in 
my  opinion,  unfounded,  and  utterly  unworthy  of  the 
least  attention  in  the  present  state  of  medical  sci- 
ence; the  termination  of  all  diseases  being,  sooner 
or  later,  in  proportion  to  the  action  of  the  predis- 
posing and  immediately  operative  causes, 


(     14     5 


CAUSES. 

These  I  have  divided  in  the  following  manner: 

1 .  Those  which  may  occur  during  pregnancy. 

2.  Those  which  occasionally  take  place  during 
parturition. 

3.  Those  which  generally  produce  this  disease 
after  delivery. 

1 .  That  class  of  society  whose  circumstances  in 
life  will  not  admit  of  any  alteration  in  diet,  regi- 
men, or  exercise,  during  pregnancy,  but  who  are 
obliged  to  attend  to  their  ordinary  domestic  con- 
cerns from  necessity,  generally  pass  through  the 
pregnant,  parturient,  and  child-bed  states  with  less 
danger  and  disease  than  those  females  who  are 
placed  in  more  affluent  circumstances. 

In  order  to  establish  the  truth  of  this  assertion, 
we  need  only  have  recourse  to  the  aborigines  of  this 
country,  and  the  uncivilized  inhabitants  of  southern 
Africa,  whose  savage  manners  have  entailed  upon 
the  women  the  most  servile  and  active  employments, 
whose  constitutions,  thus  invigorated  by  labour,  and 
untainted  by  luxury,  exempt  them  from  a  nume- 
rous train  of  diseases,  which  always,  in  civilized  so- 
ciety, have  accompanied  the  introduction  of  modern 
indolence  and  refinement. 

The  majority  of  diseases  which  are  incident  to 
women  in  the  pregnant  state,  arise  merely  from 
the  mechanical  effect  of  the  gravid  uterus,  and  con- 


On  Puerperal  Fever.  15 

sequently  disappear  after  parturition,  which  is  the1 
only  remedy  calculated  to  remove  them  effectually., 
To  enumerate  all  these  would  be  going  beyond  the 
limits  which  I  have  prescribed  for  this  dissertation. 
The  principal  part  of  those,  however,  which  are  the 
object  of  medical  attention,  I  shall  here  barely  enu- 
merate, as  causes  tending  to  the  production  of  fever 
after  delivery.  Vomiting,  indigestion  or  loss  of  ap- 
petite, costiveness  or  collections  of  indurated  faeces 
in  the  intestines,  tenesmus,  diarrhoea,  stranguary, 
and  dysenteric  complaints;  all  which,  if  not  re- 
moved or  alleviated  by  proper  treatment,  will  in- 
duce a  dangerous  degree  of  indirect  debility,  and 
render  the  patient  more  liable  to  the  operation  of 
febrile  causes,  thus  laying  a  foundation  for  this  ma- 
lignant and  frequently  fatal  disease. 

But  among  those  causes  which,  independent  of 
the  mechanical  action  of  the  gravid  uterus,  are 
operative  in  the  production  of  this  disease,  may  be 
classed  the  two  extremes  of  undue  indolence  and 
exercise.  The  first  has  a  tendency  to  induce  a 
plethoric  state  of  the  system ;  the  last  produces  such 
exhaustion  as  to  render  the  patient  incapable  of 
undergoing  the  fatigues  of  child-birth.  A  diet  more 
nourishing  than  the  patient  has  been  accustomed 
to,  or  less  stimulating  than  that  used  in  a  state  of 
health;  living  in  an  unhealthy  atmosphere;  and 
want  of  attention  to  cleanliness  and  proper  cloath- 
ing  for  the  season,  may  all  be  considered  as  causes 
predisposing  to  this  disease. 

2.  Harsh  and  rude  examination  by  the  accou- 


16  On  Puerperal  Fever. 

cheur,  tending  to  excite  inflammation;  the  vio- 
lence done  in  preternatural  labours,  to  the  organs 
of  generation  and  the  neighbouring  parts ;  the  hasty 
and  improper  extraction  of  the  placenta  5  the  im- 
prudent exhibition  of  stimulating  drinks,  and  the 
use  of  various  other  artificial  means  to  excite  pains, 
and  expedite  the  expulsion  of  the  contents  of  the 
uterus,  are  also  to  be  considered  as  predisposing 
causes. 

3.  Under  this  head  maybe  enumerated  all  those 
causes  which  originate  from  the  mismanagement  of 
the  patient  after  delivery,  in  those  cases  where  she 
has  passed  through  the  pregnant  and  parturient 
states  without  experiencing  any  untoward  symp- 
toms of  disease.  Formerly  it  was  the  practice  (and 
I  am  sorry  to  observe  that  the  treatment  is  now  not 
altogether  abandoned)  to  give  patients  large  quan- 
tities of  vinous  drinks;  and  even  those  who  had 
scarcely  ever  tasted  of  spirituous  liquors  were  ob- 
liged to  drink  almost  to  intoxication  during  and 
immediately  after  delivery,  in  order,  as  was  said, 
to  strengthen  them,  and  promote  their  speedy  reco- 
very from  the  exhaustion  produced  in  consequence 
of  parturition;  no  fresh  air  was  admitted  into  their 
apartments;  the  doors  and  windows  of  their  cham- 
bers were  closed.  In  this  situation  they  were  con- 
fined, loaded  with  bed-clothes,  for  a  number  of 
days,  destitute  of  a  healthy  atmosphere,  labouring 
under  increased  excitement  in  consequence  of  the 
application  of  stimuli  administered.  The  patients 
were  placed  in  a  horizontal  position,  the  lochial 


On  Puerperal  Fever,  17 

discharge  was  impeded,  which,  of  consequence^ 
accumulated  in  the  uterus  and  folds  of  the  vagina  -y 
there  became  acrid,  and  operated  as  an  extraneous 
stimulating  material,  excoriating  and  inflaming  the 
parts,  and  consequently  preventing  the  natural  se- 
cretion of  it  from  the  uterus.  The  retention  of 
that  material  which  was  intended  by  nature  to  be 
secreted  from  the  system,  together  with  that  lodged 
in  the  vagina  and  uterus,  in  addition  to  the  mal- 
treatment above  mentioned,  were  all  so  many  ex- 
citing causes  of  puerperal  fever. 

It  notwithstanding  often  happens  in  cases  where 
there  is  no  cause  for  complaint  respecting  the 
treatment,  that  patients  will  be  attacked  with 
this  disease,  which  must  be  referred  to  the  opera- 
tion of  atmospheric  influence  in  those  seasons  of 
the  year  when  epidemic  fevers  prevail.  In  the 
autumn  of  180S,  and  every  other  year  when  the 
principal  towns  in  America  were  visited  with  yel- 
low fever,  it  was  remarked  that  many  parturient 
women  in  those  towns  were  seized  with  this  dis- 
ease, which  put  on  a  very  alarming  appearance, 
and  proved  fatal  to  the  greatest  proportion  of 
them. 

I  need  not  here  insert  the  numerous  instances 
related  by  medical  authors  of  the  fatal  ravages  com- 
mitted by  this  disease  in  lying-in  wards  of  Euro- 
pean hospitals,  particularly  those  crowded  with 
patients. 

When  we  come  to  examine  the  climate,  soil,  and 
situations   of  those    countries   and   places  where 

c 


18  On  Puerperal  Fever. 

puerperal  fever,  plague,  yellow  fever,  dysentery* 
bilious  remitting  and  intermitting  fevers  rage  epi- 
demically, we  will  generally  find  their  soil  low, 
marshy,  and  wet,  or  that  a  large  proportion  of 
the  surface  of  the  earth  is  covered  with  water;  the 
climate  will  commonly  be  hot,  the  falls  of  rain 
frequent  and  copious,  and  the  atmosphere  conse- 
quently loaded  with  moisture.  In  large  cities, 
where  filth  accumulates  annually,  where  the  sun's 
rays  are  powerful,  and  the  process  of  animal  and 
vegetable  putrefaction  is  most  general,  and  conse- 
quently producing  the  greatest  extrication  of  pesti- 
lential vapour ,  we  find  fevers  of  the  most  malignant 
character.  Hence  we  account  for  the  greater  pre- 
valence of  puerperal  fever  in  these  places  than  in 
the  open  country.  An  atmosphere  analogous  to 
this  may  be  generated  in  an  hospital  ward,  where 
the  nurses  do  not  pay  strict  attention  to  cleanli- 
ness and  ventilation.  The  morbid  operation  of  a 
depraved  atmosphere  upon  the  puerperal  system  is, 
in  my  opinion,  very  obvious.  The  deprivation  of  a 
sufficient  quantity  of  oxygenous  air  must  undoubt- 
edly augment  the  irritability  of  a  person  who  is  al- 
ready in  a  very  irritable  state,  induced  by  parturi- 
tion, or  any  of  the  preceding  causes;  and  it  is  not 
improbable,  that  some  of  these  noxious  materials 
may  be  mixed  with  the  saliva,  and  being  swal- 
lowed, generate  disease  in  the  stomach  and  bowels, 
or  aggravate  that  which  is  already  existing.  The 
application  of  this  putrid  and  moist  vapour  to  the 
surface  of  the  body  may  evidence  itself  in  the  sup- 


On  Puerperal  Fever.  19 

presslon  or  diminution  of  perspiration,  or  some  of  the 
other  secretions;  as  an  increase  of  the  temperature  of 
the  human  body  is  the  most  prominent  symptom  of 
fever,  which  cannot  take  place  without  a  diminution 
or  suppression  of  some  of  the  discharges  by  which 
the  heat  escapes  from  the  system.  The  suppression 
of  perspiration,  or  of  any  other  secretion,  or  the 
retention  of  any  of  those  materials  which  nature 
intended  should  be  discharged  from  the  system  as 
excrementitious,  must  operate  as  a  local  stimulant 
on  the  part  where  they  are  deposited^  and,  of  course, 
produce  increased  action  in  the  sanguineous  system, 
and  consequent  inflammation  on  those  parts  which 
were  previously  in  a  state  of  the  greatest  irritability. 
Does  not  the  uterus,  and  adjacent  parts  which  have 
participated  of  the  effects  of  pregnancy  and  partu- 
rition, possess  the  greatest  share  of  this  morbid  sen- 
sibility? Most  certainly.  How  easy  is  it  then  to 
account  for  the  inflammation  and  its  consequences, 
gangrene  and  mortification,  of  those  parts  situated 
in  the  pelvis  and  abdomen  of  persons  who  have 
died  of  this  disease?  I  conclude,  therefore*  by  as- 
serting, that  a  concurrence  of  more  or  less  of  the 
causes  enumerated  is  always  productive  of  this 
disease. 


(20     ) 


CURE. 


All  causes  of  disease  applied  to  the  human  sys- 
tem will,  in  the  first  place,  produce  their  effects  Iot 
cally,  which  local  affection  will  communicate  dis- 
ease sympathetically  to  the  whole  system.     The  lo- 
cal affections  will  be  in  different  parts  of  the  body, 
depending  on  the  different  degrees  of  irritability  of 
those  parts,  the  various   causes  applied,    and  the 
condition  of  the  parts  to  which  they  are  applied. 
The  effects  produced  upon  the  system  by  the  appli- 
cation of  morbid  matter  will   vary   according  to 
the  various  constitutions,  temperaments,  and  idio- 
syncrasies of  the  patients.  If  they  be  previously  debi- 
litated by  any  cause  or  causes  whatever,  the  exciting 
stage,  which  takes  place  in  a  greater  or  less  degree  at 
the  commencement  of  all  fevers,  will  be  less  violent, 
and  this  excitement  will  always  be  inversely  pro- 
portionate to  the  state  of  existing  debility.    This  cir- 
cumstance in  paticular  ought  to  be  carefully  ob- 
served and  strictly  attended  to  in  this  form  of  fever, 
that  we  may  regulate  our  prescriptions  accordingly. 
Thus  it  will  be  found,  that  the  exciting  stage  of 
this  disease,   in  plethoric  women,  will  assume  an 
alarming  appearance;  while,  in  debilitated  habits, 
the  danger  of  congestion,  from  increased  action, 
will  be  much  less.     In  the  one  case  we  may  carry 
our  depleting  treatment  to  a  greater  extent;  while, 
In  the  other,  great  caution  is  requisite  in  the  admi- 


On  Puerperal  Fever.  21 

lustration  of  evacuants,  that  we  may  not  extend  it 
too  far,  and  thereby  reduce  our  patient  to  an  irre- 
coverable state  of  debility. 


INDICATIONS. 

1.  To  reduce  the  excitement  of  the  system,  and 
to  restore  the  usual  evacuations. 

2.  To  guard  the  patient  against  the  dangers  of  a 
relapse,  as  far  as  that  circumstance  shall  depend 
upon  the  application  of  the  original  causes,  and 
give  tone  to  the  system. 

The  first  indication  may  be  answered  by, 

1.  Blood-letting; 

2.  Alvine  evacuations; 

3.  The  restoration  of  the  perspirable  discharge: 

4.  Blisters;  and, 

5.  Warm  bathing  and  fomentations. 

Authors  have  differed  very  materially  on  the  sub- 
ject of  blood-letting  in  this  disease:  many  have 
contended  for  the  propriety  of  it,  while  some  have 
reprobated  the  practice,  and  entirely  proscribed  the 
use  of  the  lancet:  but  I  apprehend  that  this  differ- 
ence of  opinion  has  arisen  from  the  various  appear- 
ances of  the  disease  at  different  times;  it  being  well 
ascertained  that  the  exciting  stage  occupies  compa- 
ratively a  short  period  of  time,  and  the  disease  occurs 
under  such  circumstances,  that  the  physician  has 
not  always  an  opportunity  of  witnessing  its  first  in- 


22  On  Puerperal  Fever. 

vasion.  But  in  the  present  state  of  the  obstetric  art, 
blood-letting  is  pretty  generally  admitted  as  an  es- 
sential point  of  practice;  the  good  effects  of  which 
will  appear  obvious  from  the  following  considera- 
tions, viz.  The  prevention  of  universal  indirect  de- 
bility, which  is  always  the  product  of  high  excite- 
ment in  the  sanguineous  system;  for,  by  diminish- 
ing the  quantity  of  blood,  we  decrease  the  velocity 
and  the  volume  of  blood  to  the  inflammatory  part, 
thereby  allowing  or  exciting  the  turgid  vessels  of 
the  inflamed  part  to  contract  and  unload  their  con- 
tents, and,  of  course,  prevent  consequent  gangrene 
or  mortification.  It  is  a  point  universally  admitted, 
that  blood-letting  fits  the  system  for  the  after  ope- 
ration of  cathartic  or  diaphoretic  medicine,  and 
blisters  are  of  the  most  essential  service  when  pre- 
ceded by  venesection;  and  from  our  own  observa- 
tion, we  know  that  it  is  infinitely  more  difficult  to 
induce  perspiration  in  persons  who  have  not  been 
previously  bled  than  those  who  have;  that  it  is  al- 
most impossible  to  have  the  full  effect  of  usual 
doses  of  medicine,  without  engendering  an  aggra- 
vation of  the  disease  from  the  stimulant  power  of 
the  remedy,  unless  preceded  by  loss  of  blood. 
The  truth  of  this  last  observation  will  appear  obvi- 
ous when  we  consider  the  manner  in  which  medi- 
cines become  operative.  They  are  all  cathartic  or 
emetic,  in  proportion  to  the  stimulus  impressed 
upon  the  intestines  or  the  stomach.  Now,  the  sti- 
mulant power  of  any  agent  will  show  itself  more 
or  less  in  the  increased  action  of  the  arterial  system. 


On  Puerperal  Fever.  2$ 

This  action,  in  the  exciting  stage  of  fevers,  is  al- 
ready inordinate,  and  an  attempt  to  allay  this  arte- 
rial tumult,  by  the  exhibition  of  active  cathartics, 
independent  of  blood-letting,  will  very  generally  be 
found  abortive.  It  is  true,  that  the  depletion  occa- 
sioned by  large  doses  of  medicine  may  be  as  com- 
plete in  the  issue  as  that  arising  from  the  subdue- 
tionofany  indefinite  quantity  of  blood ;  but  the  ef- 
fects of  this  depletion  will  be  vastly  different  upon 
the  system,  in  as  much  as  the  debility  in  the  one  case 
arises  from  excess  of  stimulus,  while,  in  the  other^ 
the  exhaustion  produced,  unless  carried  beyond  a 
certain  degree,  is  nothing  more  than  a  deprivation 
of  inflammatory  action. 

The  second  mean  by  which  to  accomplish  the 
first  indication  will  be  the  administration  of  cathar- 
tic medicine*  which  will  answer  the  double  pur- 
pose of  subducting  a  part  of  the  circulating  mass 
of  fluids,  at  the  same  time  that  it  carries  off  all 
crude,  indigested,  noxious,  or  irritating  materials 
fliat  might  have  been  lodged  in  the  intestines, 
there  tending  to  produce  an  aggravation  of  the 
disease.  But  in  the  selection  of  remedies  calculated 
for  this  purpose  great  caution  is  requisite,  since 
they  may  differ  very  materially  in  the  ultimate  effect 
of  their  operation;  some  answering  both  the  above 
mentioned  purposes,  without  producing  any  incon- 
venience afterwards;  whilst  others,  from  their  dras- 
tic operation,  act  as  highly  irritating  powers  ap- 
plied to  parts  preternaturally  excited,  and  during 
their  action  producing  partial  or  local  affections, 


24  On  Puerperal  Fever. 

very  difficult  to  remove.  The  remedies  best  cal- 
culated to  answer  the  above  purposes,  without 
hazarding  any  injurious  consequences,  will  be  found 
to  be  the  neutral  salts,  and  the  olium  ricini.  Of 
the  first,  those  which  have  a  superabundant  quantity 
of  alkali,  united  with  an  acid,  which  can  easily 
be  disengaged  in  the  stomach,  are  to  be  preferred. 
The  propriety  of  administering  such  salts  will  ap- 
pear from  the  following  considerations:  In  affec- 
tions of  the  stomach  there  is  reason  to  believe 
that  an  inordinate  degree  of  acidity  exists.  This 
being  admitted,  it  follows  as  a  natural  consequence, 
that  in  the  administration  of  such  medicine  we 
are  furnished  with  means  to  convert  a  cause  of 
disease  into  a  remedy  for  its  cure.  The  remedy  ad- 
ministered being  easily  separable  into  its  compo- 
nent parts,  the  acid  in  the  stomach  will  unite  with 
the  alkali  of  the  neutral  salt,  forming  another 
salt  of  great  efficacy,  and  proving  equally  cathar- 
tic :  the  phosphate  of  soda,  and  the  citrate  of  pot- 
ash, from  their  composition,  appear  to  be  reme- 
dies extremely  well  adapted  to  the  above  purpose. 
And  as  it  is  of  much  importance  that  we  guard 
against  any  disagreeable  affection  of  the  stomach 
and  bowels,  arising  from  the  administration  of  a 
remedy,  the  olium  ricini,  which  is  a  favourite  me- 
dicine in  this  disease,  should  be  perfectly  free  from 
any  rancidity,  void  of  that  empyreuma  which  often 
attends  it  when  drawn  by  heat;  it  should  be  ob- 
tained by  expression,  and  without  taste  or  smell. 
But  since  it  often  happens,  from  the  continuance  of 


On  Puerperal  Fevei\  25 

the  disease  for  some  days,  that  an  opportunity  is 
not  afforded  of  administering  the  above-mentioned 
remedies  on  account  of  the  debility  then  existing, 
we  are  obliged  to  have  recourse  to  such  means  as 
shall  not  impair  the  strength  of  the  patient  in  their 
operation.  Of  this  kind  are  mild  injections,  which 
answer  the  purpose  of  evacuating  the  intestines,  at 
the  same  time  that  they  serve  as  fomentations  to 
those  parts  which  are  most  generally  affected. 

3.  To  produce  perspiration,  which  we  have  laid 
down  as  a  third  method,  and  to  diminish  the  excite- 
ment of  the  system,  we  know  of  nothing  which 
promises  more  benefit  than  bathing  in  water  suited 
to  the  temperature  of  the  human  body.  In  the  ap- 
plication of  this  remedy  we  ought  to  be  very  par- 
ticular in  adapting  the  heat  of  the  water  to  the  ex- 
citement of  the  system.  When  the  patient  is  la- 
bouring under  a  high  degree  of  arterial  action,  in 
consequence  of  local  inflammation,  the  bath  should 
be  a  few  degrees  below  that  of  the  surface  of  the 
body;  by  which  means  we  subduct  heat,  relax  the 
exhalants  of  the  skin,  induce  copious  perspiration, 
and,  of  course,  take  off  the  determination  to  the 
inflamed  part.  If,  however,  circumstances  should 
render  it  impossible  for  us  to  make  use  of  the  warm 
bath  universally,  it  may  be  applied  partially,  in  the 
form  of  fomentations,  with  the  addition  of  plenti- 
ful dilution,  which  will  be  conducive  to  the  same 
purpose. 

The  spiritus  mindererus,  united  with  liquid  lau- 
danum, has  been  made  use  of  by  physicians,  in  all 

D 


26  On  Puerperal  Fever. 

cases,  to  excite  a  discharge  of  perspirable  fluid  from 
the  extreme  arteries.  This  medicine,  in  my  opi- 
nion, is  not  so  advisable,  in  cases  of  this  sort,  as 
some  other  medicines  hereafter  to  be  noticed. 

Another  mean  to  effect  the  first  indication  is  the 
use  of  emetics.  The  beneficial  effects  resulting  from 
the  exhibition  of  these  must  be  evident  to  every 
practitioner,  who  considers  the  modus  operandi  of 
these  medicines  on  the  human  system ;  they  not  only 
obviate  the  nausea  and  vomiting  which  is  generally 
present  in  this  disease,  arising  from  the  direct  as- 
sociation existing  between  the  stomach  and  the  ute- 
rus, but  produce  general  perspiration  over  the  sys- 
tem, and,  consequently,  reduce  the  temperature  of 
the  body,  remove  from  the  stomach  and  upper  in- 
testines all  acrid  matters  that  may  be  accumulated; 
mechanically  stimulate  into  action  the  stomach, 
liver,  and  pancreas,  and  thus  promote  the  secretion 
of  those  fluids  which  are  so  essentially  necessary  in 
digestion,  and  in  exciting  the  peristaltic  motion  of 
the  intestines.  The  exhibition  of  this  remedy  is 
beneficial  in  all  inflammatory  diseases  after  blood- 
letting, in  as  much  as  nausea  and  vomiting  are 
known  to  produce  absorption  and  remove  inflam- 
mation by  resolution.  In  the  use  of  emetics,  we 
ought  to  be  very  careful  in  selecting  those  arti- 
cles which  operate  with  most  ease  and  safety;  such 
as  antimonial  wine,  ipecacuanha,  and  tartarized 
antimony,  united  with  prepared  chalk,  or  any 
other  absorbent  earth.  The  latter  is  highly  re- 
commended by  Dr.  Denman  in  almost  any  stage 


On  Puerperal  Fever.  27 

of  the  disease  ;  but  whatever  medicine  we  use,  it  is 
proper  in  those  delicate  states  of  the  system  to 
commence  with  small  doses  -,  and  if  these  do  not 
produce  any  sensible  evacuation,  an  increased  quan- 
tity may  be  given  after  the  expiration  of  a  proper 
period,  and  repeated  until  the  desired  effect  is  pro- 
duced ;  after  which,  if  the  symptoms  do  not  abate, 
we  must  not  hesitate,  at  any  time,  to  continue  the 
repetition  of  them  whilst  the  symptoms  shall  in- 
dicate their  use.  The  combination  of  calomel  and 
opium  will  be  found  very  useful  in  this  stage  of  the 
disease,  after  the  use  of  evacuants.  The  opium  will 
assist  in  allaying  the  irritability  of  the  system ;  the 
calomel  will  operate  as  a  gradual  and  diffusible  sti- 
mulant, and,  given  in  small  and  repeated  doses, 
produce  evacuations  from  the  bowels,  increase  per- 
spiration, restore  the  discharge  of  the  lochia,  which 
had  been  suppressed,  and  accelerate  the  discharge 
from  the  salivary  glands;  thus  acting  as  a  universal 
issue  to  the  system,  and,  consequently,  calculated 
to  discuss  inflammation  in  any  part  of  it. 

4.  If  the  pain,  swelling,  and  tenderness  of  the 
abdomen  do  not  yield  to  the  remedies  heretofore 
mentioned,  we  must,  without  delay,  have  recourse 
to  epispastics,  which  must  be  applied  directly  over 
the  part  most  affected.  These  may  always  be  re- 
commended with  safety,  and  they  will,  generally, 
produce  a  very  good  effect,  as  they  are  the  most 
powerful  means  in  removing  inflammation,  by  the 
transfer  of  excitement  which  they  produce. 


28  On  Puerperal  Fever. 

5.  In  addition  to  these  the  use  of  anodyne  fomen- 
tations may  be  admitted,  and  even  insisted  on,  as 
they  are  the  most  essential  remedies  in  our  power 
to  restore  the  lochial  discharge,  if  it  be  suppressed 
(as  most  usually  occurs),  or  to  correct  that  secre- 
tion when  vitiated  by  the  continuance  of  disease. 
Flannels,  wet  with  warm  vinegar  and  water,  united 
with  a  small  proportion  of  liquid  laudanum,  and 
wrung  almost  dry,  applied  to  the  abdomen,  and 
frequently  renewed,  have  been  found  to  answer  this 
purpose. 

Our  second  indication  is  to  guard  against  the 
danger  of  a  relapse,  as  far  as  that  circumstance 
shall  depend  upon  the  usual  occasional  or  exciting 
causes,  which  are  enumerated  in  the  third  head  of 
causes  of  this  disease:  it  remains  now  to  premise 
such  diet  as  shall  be  light  and  easy  of  digestion, 
and  an  atmosphere  pure,  cool,  and  uncontaminated, 
which  can  only  be  obtained  in  well-ventilated 
apartments,  where  cleanliness  in  every  particular, 
either  as  it  respects  the  bed  or  body  linen  of  the 
patient,  frequent  ablution,  or  the  removal  of  all 
excrementitious  materials  from  the  patient,  is  assi- 
duously attended  to,  and  carefully  observed. 

After  having  removed  the  excitement  of  the 
system,  restored  the  natural  evacuations,  and  re- 
moved local  affections,  we  proceed  to  notice  those 
remedies  which  are  calculated  to  restore  the  tone 
of  the  system,  and  to  obviate  that  debility  which 
is  induced  by  the  disease  5   and  this  is  generally 


On  Puerperal  Fever.  s  § 

easy  to  be  accomplished:  but  instances  have  oc- 
curred, and  not  unfrequently  do  occur,  where  the 
over-exhaustion  has  been  so  great  as  to  render  the 
prescriptions  of  the  most  experienced  medical  men 
ineffectual.  The  remedies  which  are  generally 
made  use  of  in  order  to  effect  this  end,  are  wine, 
opium,  bark,  blisters,  steel,  bitters,  spices,  volatile 
alkali,  cordials,  and  generous  diet.  These  reme- 
dies are  all  calculated  to  produce  the  desired  effect, 
provided  the  system  of  the  patient  is  not  reduced 
to  that  degree  which  renders  it  unsusceptible  of  the 
impressions  of  medicine. 

But  notwithstanding  all  the  exertions  of  the  most 
able  physicians,  the  disease  sometimes  progresses 
without  the  least  apparent  remission,  and  assumes 
the  alarming  and  fatal  symptoms  which  are  be- 
yond the  power  of  medicine  to  arrest.  The  most 
common  of  these  are  the  following,  which  have 
already  been  mentioned  in  the  history  of  the  dis- 
ease; viz.  involuntary  evacuation  of  the  fasces,  weak 
pulse,  syncope,  delirium,  together  with  appearances 
of  gangrene  and  mortification.  All  that  can  be 
done  by  the  physician  under  these  circumstances  is 
to  administer  anodynes  for  the  mitigation  of  the 
distresses  of  the  patient,  and  to  smooth  the  avenue 
to  the  grave. 

Knowing,  however,  that  the  symptoms  of  disease 
are  various,  and  not  unfrequently  deceitful,  and 
that  patients  have  oftentimes  recovered  from  this 
fever  contrary  to  the  expectation  of  the  most  ex- 
perienced practitioners,  we  ought  never  to  relax 


SO  On  Puerperal  Fever. 

our  attention  while  life  remains,  but  be  active  in 
the  use  of  every  remedy  which  suggests  itself  to 
our  minds.  By  thus  persevering  we  may  restore 
to  health  many  who  might  otherwise  be  irreco- 
verably lost  to  their  families,  to  their  friends,  and 
to  society. 


THE  END, 


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